Description
You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
Candidates must reside in New York (preferably around the Buffalo area).
Position Purpose:
Responsible for initial assessment and continued compliance of all pending and current delegated entities with NCQA Credentialing Guidelines and Standards to meet Fidelis Care's goals and objectives. Acts as the main Fidelis Care contact for delegated credentialing entities in regards to initial/annual credentialing audits, corrective actions and follow-up with monitoring and assessment of semi-annual reporting requirements. Prepares and reports initial and annual audit results to the Credentials Committee.
- Acts as main contact for delegated credentialing entities.
- Includes oversight, monitoring and assessment of all initial capacity audits for new delegated entity requests and all annual audits of current delegated entities (55+ delegated entities) completed by Provider Relations Staff maintaining compliance with accrediting and regulatory agencies including the NYS DOH, NCQA and CMS.
- Has strong working knowledge of the NYS statutes and laws, NCQA and CMS credentialing standards and requirements.
- Reviews and independently assesses the delegate’s information based on NYS DOH, CMS and NCQA standards.
- Assessment and review includes all file audits, attestation completion and receipt, all credentialing policy and procedures, monthly delegated roster submissions for HPN and provider directory information and semi annual/ongoing monitoring/performance reports of their credentialing program provided electronically by the delegated entity.
- Semi annual reports include, but not limited to, the names and number of practitioners credentialed and re-credentialed each month, average days to complete the process, Credentials Committee meeting dates, monthly sanction results with actions and any actions taken to rescind or deny practitioners.
- Collaborates with delegated entities to correct any deficiencies and prepares corrective action notification letters as applicable.
- Consults and provides recommendations for delegated entity compliance as needed.
- Monitors and prepares check requests for delegated credentialing payments as applicable.
- Develops and provides assessment reports, corrective action plans (if applicable) and initial/annual audit reports monthly to the Credentials Committee.
- Ability to verbalize and describe overall results and corrective actions to Credentials Committee as needed.
- Responsible for meeting timeliness and compliance with regulatory agencies, internal policy/procedures and goals and objectives for delegated credentialing.
- Manages flow of information and appropriate documentation needed for Credentials Committee review and Chief Medical Officer/Medical Director as applicable as it relates to delegated credentialing.
- Maintains the confidentiality of all delegate credentialing and recredentialing information.
- Accurately enters and/or updates data into the credentialing database as provided by the delegated entity.
- All work completed while maintaining the integrity of the credentialing database.
- Job performance requires fulfilling other incidental or related duties as assigned, assisting and training others, and performing duties of higher rated positions from time to time for developmental purposes.
- Able to be thorough and complete when working with assembling, processing, or providing detailed information; track details even when under pressure.
- Ability to independently review and assess if appropriate documentation has been received.
- Able to promote quality in spite of other pressures; identify and remove barriers to quality; take time to do things right.
- Able to anticipate and respond to customer needs, concerns, or questions in order to meet or exceed their expectations; help evaluate needs and options; show care and concern to demonstrate customer importance and value.
- Able to take action to meet the needs of others; respond to solve problems; minimize delays or problems with little or no supervision.
- Able to persevere in accomplishing tasks or objectives; have a sense of urgency about getting results.
- Performs other duties as assigned
- Complies with all policies and standards
Education/Experience:
AA/AS - Associates Degree or equivalent required. BA/BS – Bachelors Degree or equivalent preferred. 3-5 years healthcare business experience coordinating projects and adhering to deadlines, required. 5-8 years work experience in position with similar responsibilities, credentialing experience working in a managed health care organization preferred.
License/Certification: CPCS – Certified Provider Credentialing Specialist preferred.
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
